Presentation on theme: "lICENSE To Treat Failure: An updated approach"— Presentation transcript:
1 lICENSE To Treat Failure: An updated approach CDR Timothy MurrayCHF Clinic ManagerInternal Medicine TeamInpatient Pharmacy Clinical CoordinatorClaremore Indian HospitalClinical Assistant ProfessorUniversity of OklahomaPrimary Care Cardiology UpdateApril 9, 2011
2 Case #1PT is a 37 yo white male whom is being consulted to the Internal Medicine service today secondary to an CHF exacerbation. JS presented to the ER with a 5 day history of increased shortness of breath and 10 lb weight increase.Symptoms started after a recent trip where a “poor” diet was consumed.Family Hx: DM, CADSocial Hx: negativePMH: HTN, CADMedication prior to admission:Atenolol 25mg BID, aspirin 81mg daily, fish oil 1000mg daily, tamsulosin 0.4mg daily, KCL 8meq daily, furosemide 20mg daily
4 Case #1 Physical Exam: CHEST/LUNGS: Chest: Nontender Lungs: RALES Bilateral mostly at right base, no wheezingCARDOVASCULAR:Cardiac: regular rate, regular rhythm, No murmurPulses: Equal, DIMINISHED Very diminished at feet.Carotid: No bruitJVD: distendedAbd aorta: No BruitLower ext: BILATERAL Edema of both legs mostly right side 3/4 and2/4 at left.
5 Case #1PT is treated in the hospital for 3 days. Weight has decreased 15 lbs and he feels much better. PT is to be seen in the CHF clinic in 2weeks for medication adjustment, dietary education, and monitoring. Completed echocardiogram reveals an ejection fraction of 25%PT returns to CHF clinic in 2wks with the following labs:PNBP: 3200
6 Case #1Based upon the above case what type of interventions would you have expected to have been performed? (during admission or in clinic)A. Continue all medications prior to admissionB. Increase Atenolol, start an ace-inhibitor, & start an aldosterone antagonistC. DC atenolol, start metoprolol succinate, & start an ace-inhibitorD. DC atenolol, start carvedilol, & start an ace-inhibitorE. Just give up and discharge patient from clinic!!!
7 Heart Failure Background Population GroupPrevalenceIncidenceMortalityHospital DischargesCostTotal population4,900,000550,00051,546999,000$24.3 billion1Heart failure (HF) is a major public health problem resulting in substantial morbidity and mortalityMajor cost-driver of HF is high incidence of hospitalizations1,2JCAHO has initiated HF quality care indicators for hospitalized HF patients1American Heart Association Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 2002.
8 Estimated Direct and Indirect Costs of Heart Failure in US Total Cost $25.8 billionHospitalization $13.653%Nursing Home $3.514%7%8%8%Lost Productivity/ Mortality* $2.110%Physicians/Other Professionals $1.8Drugs/Other Medical Durables $2.7Home Healthcare $2.1*Lost future earnings of persons who will die in 2004, discounted by 3%AHA. Heart Disease and Stroke Statistics—2004 Update
9 Causes of Hospital Readmission for Congestive Heart Failure Over 2/3 of HF Hospitalizations PreventableDiet Noncompliance24%Rx Noncompliance24%16%Inappropriate RxApproximately 50% of the hospitalizations for acute CHF are a result of noncompliance, with 24% of readmissions due to failure to comply with diet and 24% due to failure to comply with prescribed treatments. Failure to seek care (19%), inappropriate prescribing (16%), and other reasons (17%) comprise the remainder of causes of hospital readmission for HF. “Other” includes arrhythmia-related decompensation, pneumonia, distrust of physician, acute ischemia and infections.17%Other19%Failure to SeekCareAnnals of Internal Medicine 122:415-21, 1995
10 Why a Hospital-based System for HF Management? PatientsPatient capture pointHave patient’s/family’s attention: “teachable moment”Predictor of care in communityHospital structureStandardized processes / protocols / teamsAccrediting bodies for standards of careCenters for Medicare and Medicaid Services—peer review organizationNote to field personnel: with this slide, be sure to address positive CAD and Stroke experience thus far
11 Benefits & Drawbacks of HF Disease Management Programs Improved use of evidence- based therapyImproved symptom status and functional capacityImproved QOLReduction in hospitalizationDecrease in total medical costsUsual CareAsk gregg what is the drawback…plz speak to this slideHF Disease Management ProgramMoser DK, Mann DL. Circulation. 2002;105:2810–2812.
12 How did we get into this CHF mess?? Where did our process break down and why no reduction in hospitalizations or re-hospitalizations?Sub-optimal utilization of guidelinesNo standardization of care (standing orders)No team approach to treating CHFNo increase in intensity of HF care after hospital discharge
13 How to get out of this CHF mess?? National registryDevelop a treatment plan (protocol)Utilize a team approach to treating CHFProvide a comprehensive service to monitor & make clinical alterations with patient’s treatment planProvide patient education & training to involve patients in their treatment planFollow-up on patients discharged after a CHF admission to avoid re-admission: CHF Clinic!!!!!!Implement & utilize national standards of care for CHFGET UP TO DATE WITH THE CHF GUIDELINES!Document – Document - Document!
14 CMS Center of Medicaid & Medicare Services Joint Commission/ACC/AHA Compliance rates for discharging CHF ptsJoint Commission/ACC/AHACHF Performance Measures
15 CMS CHF Core Measures 1. Documentation of discharge instructions 2. Left ventricular function assessment3. Use of ACE-I or ARB in pts with left ventricular systolic failure4. Documentation of smoking cessation
16 CMSHospitals should strongly consider implementing a process of care to ensure these measures are obtained and proper documentation occurs.The principal outcome measure of the ADHERE Registry was to assess overall hospital adherence to each of these measures for participating hospitals.
17 CMS CMS 2009 Documentation privileges for pharmacists! Electronic Health Record advantagesGIPRA Measures/Performance Improvements2010 CMS 30 day readmission policy changesBeta Blockers?
19 Guidelines Never DieCHF care driven by two sets of national guidelinesAmerican College of Cardiology/American Heart AssociationHeart Failure Society of America
20 Guidelines Never DieBoth organizations provide a set of detailed treatment guidelines for practitioners in an effort to optimize the management of chronic CHF.Treatment guidelines provide an approach to practice evidence based medicine.
21 CHF National Guidelines Heart Failure Society of AmericaLast update: June 2010American College of Cardiology/American Heart AssociationLast update: April 2009
22 Guidelines 2009 ACC/AHA recommendation for: “implementation of practice based guidelines utilizing multidisciplinary disease-management programs in efforts to assist in the treatment of patients with CHF”.
23 Guidelines 2010 HFSA recommendation for: “patients recently hospitalized for HF & other patients at high risk for HF decompensation should be considered for comprehensive HF disease management.”
24 HFSA 2010 Practice Guideline (3.2) HF Risk Factor Treatment Goals HypertensionGenerally < 130/80DiabetesSee ADA guidelines1HyperlipidemiaSee NCEP guidelines2Inactivity20-30 min. aerobic 3-5 x wk.ObesityWeight reduction < 30 BMIAlcoholMen ≤ 2 drinks/day, women ≤ 1SmokingCessationDietary SodiumMaximum 2-3 g/dayThe June 2006 AHA guide regarding exercise, “Making healthy food and lifestyle choices: Our guide for American adults,” recommends 30 minutes or more of aerobic exercise every day. The recommendations and a free brochure are available at or AHA-USA1.Journal of Cardiac Failure Vol. 16 No
25 HFSA 2010 Practice Guideline (3. 3-3 HFSA 2010 Practice Guideline ( ) Prevention—ACEI and Beta BlockersACE inhibitors are recommended for prevention of HF in patients at high risk for this syndrome, including those with:Coronary artery diseasePeripheral vascular diseaseStrokeDiabetes and another major risk factorStrength of Evidence = AACE inhibitors and beta blockers are recommended for all patients with prior MI Strength of Evidence = AJournal of Cardiac Failure Vol. 16 No
26 Management of Patients with Known Atherosclerotic Disease But No HF PlaceboHOPETreatment with ACE inhibitors decreases the risk of CV death, MI, stroke, or cardiac arrest.NEJM 2000;342: (HOPE)Lancet 2003;362:782-8 (EUROPA)Ramipril22% rel. risk red. p < .001In the HOPE study, relative risk of the composite outcome of MI, stroke, or death from CV causes in the ramipril group as compared with the placebo group was 0.78 at five years.In EUROPA the relative risk reduction of CV death, MI, or cardiac arrest was 20%.EUROPAPlaceboPerindopril20% rel. risk red. p = .0003
27 Treatment of Post-MI Patients with Asymptomatic LV Dysfunction (LVEF ≤ 40%) SAVE StudyAll-cause mortality ↓19%CV mortality ↓21%HF development ↓37%Recurrent MI ↓25%MortalityRatePlaceboCaptopril19% rel. risk reductionp = 0.019YearsPfeffer et al. NEJM 1992;327:669-77
28 HFSA 2010 Practice Guideline (7. 1, 7 HFSA 2010 Practice Guideline (7.1, 7.7) Pharmacologic Therapy: ACE InhibitorsACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40% Strength of Evidence = AACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers) Strength of Evidence = CACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.Post MI Strength of Evidence = BNon Post-MI Strength of Evidence = CJournal of Cardiac Failure Vol. 16 No
29 ACE Inhibitors in Heart Failure: From Asymptomatic LVD to Severe HF CONSENSUS(Severe Heart Failure)40% mortality at 6 mos.31% mortality at 1 year27% mortality at end of studySOLVD Prevention (Asymptomatic LVD)20% death or HF hosp.29% death or new HFSOLVD Treatment(Chronic Heart Failure)SOLVD Prevention also showed a 37% reduction in the development of new HF and a 44% reduction in multiple hospitalizations for HF.The patients in SOLVD Treatment had an LVEF < 35%. Largest reduction in deaths were among those attributed to progressive HF. There was also a 26% reduction among those who died or were hospitalized due to worsening HF.Reduced mortality in CONSENSUS due to impact on progression of disease severity, rather than on sudden cardiac death..16%mortalitySOLVD Investigators. N Engl J Med 1992;327:685-91SOLVD Investigators. N Engl J Med 1991;325:CONSENSUS Study Trial Group. N Engl J Med 1987;316:
30 ACE Inhibitors Used in Clinical Trials Generic NameTrade NameInitial Daily DoseTarget DoseMean Dose in Clinical TrialsCaptoprilCapoten6.25 mg tid50 mg tid122.7 mg/dayEnalaprilVasotec2.5 mg bid10 mg bid16.6 mg/dayFosinoprilMonopril5-10 mg qd80 mg qdN/ALisinoprilZestril, Prinivil2.5-5 mg qd20 mg qd4.5 mg/day, mg/day*QuinaprilAccupril5 mg bidRamiprilAltacemg qd10 mg qdTrandolaprilMavik1 mg qd4 mg qdNOTE THAT SPECIFIC LANGUAGE OF RECOMMENDATIONS SHOULD BE CONSULTED.*No mortality difference between high and low dose groups, but 12% lower risk of death or hospitalization in high dose group vs. low dose group.
31 HFSA 2010 Practice Guideline (7 HFSA 2010 Practice Guideline (7.2) Pharmacologic Therapy: Substitutes for ACEIIt is recommended that other therapy be substituted for ACE inhibitors in the following circumstances:In patients who cannot tolerate ACE inhibitors due to cough, ARBs are recommended.Strength of Evidence = AThe combination of hydralazine and an oral nitrate may be considered in such patients not tolerating ARBs Strength of Evidence = CPatients intolerant to ACE inhibitors from hyperkalemia or renal insufficiency are likely to experience the same side effects with ARBs. In these cases, the combination of hydralazine and an oral nitrate should be considered.Strength of Evidence = CJournal of Cardiac Failure Vol. 16 No
32 HFSA 2010 Practice Guideline (7. 6, 7 HFSA 2010 Practice Guideline (7.6, 7.7) Pharmacologic Therapy: Beta BlockersBeta blockers shown to be effective in clinical trials are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%.Strength of Evidence = ABeta blockers are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.Post MI Strength of Evidence = BNon Post-MI Strength of Evidence = CBeta blockers shown to be effective in clinical trials include carvedilol, bisoprolol, and metoprolol succinate. See slide 17.Journal of Cardiac Failure Vol. 16 No
33 Effect of Beta Blockade on Outcome in Patients With HF and Post-MI LVD StudyDrugHF SeverityTarget Dose (mg)OutcomeUS Carvedilol1carvedilolmild/ moderateBID↓48% disease progression (p= .007)CIBIS-II2bisoprololmoderate/ severe10 QD↓34% mortality (p <.0001)MERIT-HF3metoprolol succinate200 QD↓34% mortality (p = .0062)COPERNICUS4severe25 BID↓35% mortality (p = .0014)CAPRICORN5post-MI LVD↓23% mortality (p =.031)1Colucci WS et al. Circulation 1196;94: CIBIS II Investigators. Lancet 1999;353:9-13.3MERIT-HF Study Group. Lancet 1999;353: Packer M et al. N Engl J Med 2001;344The CAPRICORN Investigators. Lancet 2001;357:
34 HFSA 2010 Practice Guideline (7 HFSA 2010 Practice Guideline (7.8) Pharmacologic Therapy: Beta BlockersBeta blocker therapy is recommended for patients with a recent decompensation of HF after optimization of volume status and successful discontinuation of IV diuretics and vasoactive agents.Whenever possible, beta blocker therapy should be initiated in the hospital at a low dose prior to discharge of stable patients Strength of Evidence = BJournal of Cardiac Failure Vol. 16 No
35 HFSA 2010 Practice Guideline (7 HFSA 2010 Practice Guideline (7.11) Pharmacologic Therapy: Beta BlockersContinuation of beta blocker therapy is recommended in most patients experiencing a symptomatic exacerbation of HF during chronic maintenance treatment, unless they develop cardiogenic shock, refractory volume overload, or symptomatic bradycardia Strength of Evidence = CTemporary dose reduction may be consideredAvoid abrupt discontinuationReinstate or gradually increase prior to dischargeTitrate dose to previously tolerated dose as soon as possibleJournal of Cardiac Failure Vol. 16 No
36 Carvedilol Predischarge Initiation Postdischarge Initiation* IMPACT-HF Primary End Point: Patients Receiving Beta Blocker at 60 DaysImprovement18%Initiation of a beta blocker prior to hospital discharge is safe and well tolerated in the majority of patients and dramatically improves utilization of this evidence-based therapy following discharge.Carvedilol Predischarge Initiation(n=185)Physician DiscretionPostdischarge Initiation*(n=178)Gattis WA et al. JACC 2004;43:
37 HFSA 2010 Practice Guideline (7 HFSA 2010 Practice Guideline (7.9) Pharmacologic Therapy: Beta BlockersCONCOMITANT DISEASEBeta blocker therapy is recommended in the great majority of patients with HF and reduced LVEF—even if there is concomitant diabetes, chronic obstructive lung disease or peripheral vascular disease.Use with caution in patients with:Diabetes with recurrent hypoglycemiaAsthma or resting limb ischemia.Use with considerable caution in patients with marked bradycardia (<55 bpm) or marked hypotension (SBP < 80 mmHg).Not recommended in patients with asthma with active bronchospasm Strength of Evidence = CJournal of Cardiac Failure Vol. 16 No
38 Diabetes and the Use of Beta Blockers for HF: Relative Risk for Mortality and Hospitalization for Heart FailureCOPERNICUS (carvedilol)1With diabetesWithout diabetesMERIT-HF (ER metoprolol succinate)20.51.01.52.0This slide shows relative risks for the combined end point of mortality and hospitalization owing to heart failure in patients with and without diabetes in the COPERNICUS1 and MERIT-HF2 trials.1. Mohacsi P, Fowler MB, Krum H, et al. Should physicians avoid the use of beta-blockers in patients with heart failure who have diabetes? Results of the COPERNICUS Study. Circulation. 2001;104(17):abstr 3551.2. Hjalmarson A, Goldstein S, Fagerberg B, et al. Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure (MERIT-HF). JAMA. 2000;283(10):Mohacsi. Circulation. 2001;104(17):abstr 3551.Hjalmarson. JAMA. 2000;283(10):1295.
39 HFSA 2010 Practice Guideline (11. 8, 15 HFSA 2010 Practice Guideline (11.8, 15.2) Pharmacologic Therapy: Beta BlockersPRESERVED LVEFBeta blocker treatment is recommended in patients with HF and preserved LVEF who have:Prior MI Strength of Evidence = AHypertension Strength of Evidence = BAtrial fib. requiring control of ventricular rate Strength of Evidence = BTHE ELDERLYBeta-blocker and ACE inhibitor therapy is recommended as standard therapy in all elderly patients with HF due to LV systolic dysfunction Strength of Evidence = BIn the absence of contraindications, these therapies are also recommended in the very elderly (age > 80 years).There are no studies looking specifically at the impact of beta blockers on patients with HF and preserved LVEF or on the elderly with HF. However, the use of beta blockers in patients with HF and the concomitant conditions listed in this recommendation is well established, and the elderly are represented in most HF trials.Strength of Evidence = CJournal of Cardiac Failure Vol. 16 No
40 HFSA 2010 Practice Guideline Pharmacologic Therapy: Beta Blocker Overview* General considerationsInitiate at low dosesUp-titrate gradually, generally no sooner than at 2 week intervalsUse target doses shown to be effective in clinical trialsAim to achieve target dose in 8-12 weeksMaintain at maximum tolerated doseIf symptoms worsen or other side effects appearAdjust dose of diuretic or concomitant vasoactive med.Continue titration to target after symptoms return to baselineIf up-titration continues to be difficultProlong titration intervalReduce target doseConsider referral to a HF specialistNOTE THAT SPECIFIC LANGUAGE OF RECOMMENDATIONS SHOULD BE CONSULTED.Journal of Cardiac Failure Vol. 16 No
41 Beta Blockers Used in Clinical Trials Generic NameTrade NameInitial Daily DoseTarget DoseMean Dose in Clinical TrialsBisoprololZebeta1.25 mg qd10 mg qd8.6 mg/dayCarvedilolCoreg3.125 mg bid25 mg bid37 mg/dayCoreg CR80 mg qdMetoprolol succinate CR/XLToprol XLmg qd200 mg qd159 mg/dayNOTE THAT SPECIFIC LANGUAGE OF RECOMMENDATIONS SHOULD BE CONSULTED.
42 HFSA 2010 Practice Guideline (7 HFSA 2010 Practice Guideline (7.3) Pharmacologic Therapy: Angiotensin Receptor BlockersARBs are recommended for routine administration to symptomatic and asymptomatic patients with an LVEF ≤ 40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency.Strength of Evidence = AJournal of Cardiac Failure Vol. 16 No
43 ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative PlaceboSurvival %ValsartanCV Death or HF Hosp %PlaceboCandesartanThe Val-HeFT paper cited here is a sub-group analysis of study participants not on an ACE inhibitor (N=366); they were not defined as ACE-intolerant. This table shows a reduction in all-cause mortality from 27.1% in the placebo group to 17.3% in the group treated with valsartan.CHARM-Alternative enrolled 2028 patients not receiving ACEI due to previous intolerance. Primary outcome was composite of cardiovascular death or hospital admission for HF. At median follow up of 33.7 months, 33% of the patients in the candesartan group and 40% of the patients in the placebo group had CV death or HF hospitalizationp = 0.017HR 0.77, p =MonthsMonthsMaggioni AP et al. JACC 2002;40:1422-4Granger CB et al. Lancet 2003;362:772-6
44 Angiotensin Receptor Blockers Used in Clinical Trials Generic NameTrade NameInitial Daily DoseTarget DoseMean Dose in Clinical TrialsCandesartanAtacand4-8 mg qd32 mg qd24 mg/dayLosartanCozaarmg qd150 mg qd129 mg/dayValsartanDiovan40 mg bid160 mg bid254 mg/dayNOTE THAT SPECIFIC LANGUAGE OF RECOMMENDATIONS SHOULD BE CONSULTED.
45 HFSA 2010 Practice Guideline (7. 14-7 HFSA 2010 Practice Guideline ( ) Pharmacologic Therapy: Aldosterone AntagonistsAn aldosterone antagonist is recommended for patients on standard therapy, including diuretics, who have:NYHA class IV HF (or class III, previously class IV) HF from reduced LVEF (≤ 35%)One should be considered in patients post-MI with clinical HF or diabetes and an LVEF < 40% who are on standard therapy, including an ACE inhibitor (or ARB) and a beta blocker.Renal function issues on next slide.Strength of Evidence = AJournal of Cardiac Failure Vol. 16 No
46 Aldosterone Antagonists in HF EPHESUS (Post-MI)RALES (Advanced HF)EplerenoneProbability of SurvivalSpironolactonePlaceboPlaceboRR = 0.70P < 0.001RR = 0.85P < 0.008MonthsPitt B. N Engl J Med 1999;341:709-17Pitt B. N Engl J Med 2003;348:
47 Aldosterone antagonists are not recommended when: HFSA 2010 Practice Guideline ( ) Aldosterone Antagonists and Renal FunctionAldosterone antagonists are not recommended when:Creatinine > 2.5mg/dL (or clearance < 30 mL/min)Serum potassium> 5.0 mmol/LTherapy includes other potassium-sparing diureticsStrength of Evidence = AIt is recommended that potassium be measured at baseline, then 1 week, 1 month, and every 3 months Strength of Evidence = ASupplemental potassium is not recommended unless potassium is < 4.0 mmol/L Strength of Evidence = AStarting doses: Spironolactone 12.5 mg PO QD (or 6.25 mg in high risk patient); Epleronone 25 mg QDTarget doses: Advance spironolactone at 4 weeks to 25mg PO QD;Advance epleronone at 4 weeks to 50 mg QDAvoid higher dosesJournal of Cardiac Failure Vol. 16 No
48 EMPHASIS-HFTrial of 2737 patients with NYHA class 2 heart failure and an ejection fraction of no more than 35%.Patients were randomized to eplerenone (up to 50mg daily) or placebo in addition to recommended therapy.Measured outcomes included: cardiovascular death/heart-failure hospitalization, cardiovascular death, heart-failure hospitalization, and hospitalization for hyperkalemia.Trial was stopped early at 21months.
49 Adjusted hazard ratio (95% CI) EMPHASIS-HFEMPHASIS-HF Major resultsResults in a 37% reduction in the primary end point of the composite of death from cardiovascular causes or hospitalization for heart failure!!Hyperkalemia occurring in 11.8% of eplerenone patients vs 7.2% of those in placebo group!!!OutcomeEplerenone (%)Placebo (%)Adjusted hazard ratio (95% CI)PCardiovascular death/heart-failure hospitalization18.325.90.63 ( )< 0.001Cardiovascular death10.813.50.76 ( )0.01Heart-failure hospitalization12.018.40.58 ( )Hospitalization for hyperkalemia0.30.21.15 ( )0.85
50 HFSA 2010 Practice Guideline (7 HFSA 2010 Practice Guideline (7.19) Pharmacologic Therapy: Hydralazine and Oral NitratesA combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy, in addition to beta-blockers and ACE-inhibitors, for African Americans with HF and reduced LVEF:NYHA III or IV HF Strength of Evidence = ANYHA II HF Strength of Evidence = BThis represents one of the key differences between the HFSA guideline and the AHA/ACC guideline, since this is a stronger recommendation for HDZN/ISDN.Journal of Cardiac Failure Vol. 16 No
51 A-HeFT Outcomes End point ISDN-HDZN (n=518) Placebo (n=532) p Primary end point composite score-0.1-0.50.01All-cause mortality (%)6.210.20.021st HF hospitalization (%)16.424.40.001Change in quality-of-life score at 6 months**-5.5-2.7A-HeFT: African American Heart Failure TrialComposite endpoint includes last three items on table:All-cause mortalityFirst HF hospitalizationChange in QOL score at 6 months (lower score indicates better QOL)Study enrolled 1050 self-reported African American patients will NYHA III-IV HF.Data monitoring board stopped study after 10 months of follow up due to mortality increase in placebo group.Significant outcomes showed a 43% decrease in mortality and a 39% drop in HF hospitalizations among those in the group receiving isisorbide dinitrate/hydralazine.A-HeFT used a novel primary end point consisting of weighted values for all-cause death, first hospitalization for HF, and change in quality of life according to the Minnesota Living with Heart Failure questionnaire. Possible scores ranged from +6 to -2.Taylor AL et al. N Engl J Med 2004; 351;
52 A-HeFT All-Cause Mortality 43% Decrease in MortalitySurvival %Fixed Dose ISDN/HDZNPlaceboP = 0.01Days Since Baseline VisitTaylor AL et al. N Engl J Med 2004;351:
53 HFSA 2010 Practice Guideline (7.23) Pharmacologic Therapy: Diuretics Diuretic therapy is recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by:Congestive symptomsSigns of elevated filling pressures Strength of Evidence = ALoop diuretics rather than thiazide-type diuretics are typically necessary to restore normal volume status in patients with HF Strength of Evidence = BCongestive symptoms include orthopnea, edema, and shortness of breath.Signs of elevating filling pressures include jugular venous distention, peripheral edema, pulsatile hepatomegaly, and, less commonly, rales.Journal of Cardiac Failure Vol. 16 No
54 HFSA 2010 Practice Guideline (7.24) Pharmacologic Therapy: Diuretics Restoration of normal volume status may require multiple adjustments.Once a diuretic effect is achieved with short-acting loop diuretics, increase frequency to 2-3 times a day if necessary, rather than increasing a single dose.Strength of Evidence = BOral torsemide may be considered in patients exhibiting poor absorption of oral medication or erratic diuretic effect Strength of Evidence = CIV administration of diuretics may be necessary Strength of Evidence = ADiuretic refractoriness may represent patient nonadherence, a direct effect of diuretic use on the kidney, or progression of underlying dysfunction.Journal of Cardiac Failure Vol. 16 No
55 HFSA 2010 Practice Guideline (9. 1, 9 HFSA 2010 Practice Guideline (9.1, 9.4) Device Therapy: Prophylactic ICD PlacementProphylactic ICD placement should be considered in patients with an LVEF ≤35% and mild to moderate HF symptoms:Ischemic etiology Strength of Evidence = ANon-ischemic etiology Strength of Evidence = BIn patients who are undergoing implantation of a biventricular pacing device, use of a device that provides defibrillation should be considered.Strength of Evidence = BDecisions should be made in light of functional status and prognosis based on severity of underlying HF and comorbid conditions, ideally after 3-6 mos. of optimal medical therapy Strength of Evidence = CBefore placement, LV function should be re-assessed, ideally after 3-6 months of optimal medical therapy.Journal of Cardiac Failure Vol. 16 No
56 Fluid and sodium restriction Diuretics, especially loop diuretics HFSA 2010 Practice Guideline ( ) Overview of Treatment Options for Patients with Acute Decompensated HFFluid and sodium restrictionDiuretics, especially loop diureticsUltrafiltration/renal replacement therapy (in selected patients only)Parenteral vasodilators * (nitroglycerin, nitroprusside, nesiritide)Inotropes * (milrinone or dobutamine)Journal of Cardiac Failure Vol. 16 No
57 HFSA 2010 Practice Guideline (12. 25, Table 12 HFSA 2010 Practice Guideline (12.25, Table 12.7) Discharge Criteria for Hospitalized ADHF PatientsRecommended prior to discharge for all patients with HF:Exacerbating factors addressedNear optimum fluid status and pharmacologic therapy achievedTransition from IV to oral diuretic completedPatient education completed with clear discharge instructionsFollow-up clinic visit scheduled, usually 7-10 daysShould be considered prior to discharge for patients with advanced HF or a history of recurrent admissions:Oral regimen stable for 24 hoursNo IV inotrope or vasodilator for 24 hoursAmbulation before discharge to assess functional capacityPlans for post-discharge managementReferral for disease management, if availableItems for post discharge planning: scale present in the home, visiting nurse or telemanagement follow up within 3 days of discharge.Strength of Evidence =CJournal of Cardiac Failure Vol. 16 No
58 Predictors of Mortality Based on Analysis of ADHERE Database Classification and Regression Tree (CART) analysis of ADHERE data shows:Three variables are the strongest predictors of mortality in hospitalized ADHF patients:BUN > 43 mg/dLSystolic blood pressure < 115 mmHgSerum creatinine > 2.75 mg/dLFonarow GC et al. JAMA 2005;293:572-80
59 HFSA 2010 Practice Guideline (8.1) Heart Failure Patient Education It is recommended that patients with HF and their family members or caregivers receive individualized education and counseling that emphasizes self-care.This education and counseling should be delivered by providers using a team approach.Teaching should include skill building and target behaviors.Strength of Evidence = BThe most intensive education is needed for patients in NYHA class III-IV.Examples of skills and target behaviors:Perform daily weightsDevelop action plan for notifying provider if symptoms changeState reasons for taking medicationsDescribe a plan for a missed doseState blood pressure goal and current blood pressureDemonstrate ability to read food label for sodium per servingJournal of Cardiac Failure Vol. 16 No
60 Evidence-Based Treatment Across the Continuum of Systolic LVD and HF Control VolumeImprove Clinical OutcomesDiureticsRenal ReplacementTherapy*Digoxin-BlockerACEIor ARBAldosteroneAntagonist or ARBTreat Residual SymptomsCRT an ICD*HDZN/ISDN*Clinical outcomes include reduced mortality, HF hospitalizations, and progressive LV remodeling.*In selected patients
61 AntiplateletsFor years the discussion has been which antiplatelet regimen is ideal for CHF pts?ASAWarfarinPlavixWASH TrialWATCH Trial
62 Congestive Heart Failure Hypertension Age > 75 Diabetes Risk StratificationCHADS2Congestive Heart FailureHypertensionAge > 75DiabetesStroke or TIA (2 points)
63 Risk Stratification CHA2DS2-VAS Score Congestive heart failure/LV 1 dysfunctionHypertensionAge > 75 years 2Diabetes mellitus 1Stroke/TIAVascular disease (prior MI, peripheral vascular disease)Age years 1Female sex
65 Selecting an Antiplatelet “Gadget” Patient FactorsASAPlavixWarfarinEF% < 30%XSystolic Failure w/ EF% >30%Diastolic FailureSevere CAD (no surgery option)LVAD
66 HFSA 2010 Practice Guidelines New RecommendationVTE prophylaxsis with low dose unfractionated heparin, LMWH, or fondaparinux to prevent proximal deep venous thrombosis and pulmonary embolism is recommended for patients who are admitted to the hospital with ADHF and who are not already anticoagulated & have no contraindication.(Strength of Evidence=B)
67 A View To A Trial IMPROVE-HF Omega-3 (PUFAs) SELECT Trial Irbesartan Yancy CW, Fonarow GC, Albert NM, et al. Influence of patient age and sex on delivery of guideline-recommended heart failure care in the outpatient cardiology practice setting: Findings from IMPROVE HF. American Heart Journal. 2009;157:Omega-3 (PUFAs)Tavazzi L, Maggioni AP, Marchioli R, et al. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomized, double-blind, placebo-controlled trial. Lancet 2008;372:SELECT TrialZebrack J, Munger M, MacGregor J, et al. B-Receptor Selectivity of Carvedilol and Metoprolol Succinate in Patients with Heart Failure (SELECT Trial): A randomized Dose-Ranging Trial. Pharmacotherapy. 2009;29(8):IrbesartanMassie b, Carson P, et al. Irbesartan in Patients with Heart Failure & Preserved Ejection Fraction (I-Preserve Trial). NEJM. 2008;359(23):HFSA “The Heart Failure Clinic A Consensus Statement”J Card Fail. 2008;14:Centers for Medicare and Medicaid Services 30 day congestive heart failure readmission rates.
69 No significant differences in the patients’ global assessment of symptoms or in changes from baselinerenal function with either bolus as compared with continuous infusion of intravenous furosemide orwith a low-dose strategy as compared with a highdose strategy.
72 From Seattle With Love Teaching tool to utilize with CHF patients Provides 5yr survival rate for patients based upon clinical history and no intervention as compared to rate after intervention.User friendlyInternet based
75 Case #1Based upon the above case what type of interventions would you have expected to have been performed? (during admission or in clinic)A. Continue all medications prior to admissionB. Increase Atenolol, start an ace-inhibitor, & start an aldosterone antagonistC. DC atenolol, start metoprolol succinate, & start an ace-inhibitorD. DC atenolol, start carvedilol, & start an ace-inhibitorE. Just give up and discharge patient from clinic!!!
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